Is Prostate Screening Right for Me?

Statistics show that universal prostate screening may cause more harm than good for the majority of men. But what if you're in that minority percentage that could benefit? Should you take a chance?

Prostate Cancer Screening: Should I Have a PSA Test? Talk with your physician, know risks and benefits, and decide what is right for you.

Among American men, prostate cancer is the second most common cancer (after skin cancer), and the second leading cause of cancer death (after lung cancer) [1]. Although the number of men with prostate cancer is large, most diagnosed men do not die from it.

Screening for prostate cancer has become a routine part of many men’s annual physicals. But studies show that a substantial percent of the prostate cancers detected this way will not grow, or will grow so slowly that lifespan is not threatened: these men will die with prostate cancer, not of it.

In fact the U.S. Preventive Services Task Force (USPTF) no longer recommends routine prostate-specific antigen (PSA)-based screening for prostate cancer. The American Urological Association recently stated that men 55-69, should consider PSA testing only after discussing the benefits and harms of screening with their doctors, and that screening for men of average risk between 40-55, and for men under age 40 is not recommended. [2]

PSA screening is not perfect, but it is the best test we have. Before the blood test for PSA levels became available in the 1990s, 20 percent of men with prostate cancer already had serious metastatic disease by the time they were diagnosed; less than 4 percent do now. Given the high stakes involved, why wouldn’t you opt for PSA screening-what if you happen to have the aggressive form of prostate cancer?

Prostate screening complications: causing harm?

While PSA screening can detect possible signs of early-stage prostate cancer, PSA levels can be elevated due to causes other than cancer, and there is no way to distinguish the dangerous from the slow growing tumors. Studies do not show that screening is saving lives, and many people are unaware of the risks associated with early detection and treatment. The USPTF report cautions that the benefits of early detection and treatment of prostate cancer may not outweigh the possible harms, which include:

Is prostate cancer screening right for me?

Dr. Elias Hyams consulting with a patient.

Dr. Elias Hyams, a NCCC prostate-cancer specialist and researcher, advises a “risk adaptive” approach to PSA screening. “What we haven’t done well in the past is screen the right patients,” he says. “I think more thoughtful use of PSA and other screening information is what’s called for.”

In a recent grand rounds lecture he described a risk adapted approach to screening for prostate cancer, where physicians help men to weigh the risks and benefits involved in screening so that they can make informed decisions:

prostate cancer screening is offered to healthy men (with at least 10 years life expectancy); elderly men or those with serious illness are not screened

physicians discuss the benefits and harms of screening including risk factor assessments (family history, race, nationality, age) to help the patient make informed decisions

an initial screening test (age 45) can be used as a baseline to help establish an individual’s level of risk for prostate cancer and help with future detections and treatment

monitor low-risk cancer with active surveillance (PSA testing, digital rectal exams, and when appropriate biopsies) so cancer does not become more aggressive over time

Consider the risks and benefits, and decide what is right for you

Enlarge. An infographic illustrating the benefit and harms of PSA screening for prostate cancer. Source: cancer.gov

You might feel comfortable with this approach to screening, but waiting to start treatment may reduce the chance to control cancer before it spreads. Regular checkups during active surveillance reduces this risk, but and for some men it's stressful to live with untreated prostate cancer. Prostate Cancer Screening: Should I Have a PSA Test? can help you get the facts, compare your options, and explore your feelings about the options so you can make an informed decision. Talk with your physician, know risks and benefits, and decide what is right for you.

Age: Prostate cancer is very rare in men younger than 40. Almost 2 out of every 3 prostate cancers are found in men over the age of 65.

Race: Prostate cancer is more common in African-American men than in men of other races. African-American men are also more likely to have a more advanced disease when it is found and are more likely to die of the disease.

Nationality: Prostate cancer is most common in North America, northwestern Europe, and a few other places. It is less common in Asia, Africa, Central and South America.

Family history: Prostate cancer seems to run in some families. Men with close family members (father or brother) who have had prostate cancer are more likely to get it themselves, especially if their relatives were young when they got the disease. (The risk is higher for men who have a brother with the disease than for those with an affected father.)

Genes: Scientists have found some inherited genes that seem to raise prostate cancer risk, but they probably account for only a small number of cases overall. Genetic testing for most of these genes is not yet available, and more study is needed in this area.